NPIMap

Organization Active NPI

Revive Orthopedics Spine & Sports Medicine, Inc

Doing business as Revive Orthopedics Spine & Sports Medicine

  • Durable Medical Equipment & Medical Supplies
  • Loganville, GA
National Provider Identifier
1841900636
Registry record updated Dec 1, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Durable Medical Equipment & Medical SuppliesTaxonomy code 332B00000X
Legal business name
REVIVE ORTHOPEDICS SPINE & SPORTS MEDICINE, INC
Doing business as
Revive Orthopedics Spine & Sports Medicine
Practice address
3955 Harrison Rd Ste 200B
Loganville, GA 30052-8502
Phone
(770) 209-9913
Fax
(678) 902-8579
NPI assigned
Dec 1, 2022
Organization subpart
Yes
Parent organization
REVIVE ORTHOPEDICS SPINE & SPORTS MEDICINE, INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Dec 1, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Shevin D Pollydore, MD
Title
Physician/Owner
Phone
(770) 209-9913

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X Primary
Pharmacy 333600000X

Addresses

Primary practice location

3955 Harrison Rd Ste 200B
Loganville, GA 30052-8502

Mailing address

3955 Harrison Rd Ste 200B
Loganville, GA 30052-8502
Phone (770) 209-9913

Other names 1

  • Revive Orthopedics Spine & Sports Medicine Doing business as

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
11D2339557Revive Orthopedics Spine & Sports Medicine3955 Harrison Road, Suite 200 B, Loganville, GA 30052Certificate of waiverMar 3, 2028

National Provider Directory

National Provider Directory
Tax ID family
Revive Orthopedics Spine Sports Medicine Inc6 organizations share this tax ID, including this one
Part of
Revive Orthopedics Spine Sports Medicine Inc

Other organizations with this tax ID 5

Organizations that report the same tax identification number in the National Provider Directory.

Locations

3955 Harrison Rd
Ste 200B
Loganville, GA 30052
Phone (770) 209-9913

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1669852800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1669852800000",
    "number": "1841900636",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3955 HARRISON RD STE 200B",
            "city": "LOGANVILLE",
            "state": "GA",
            "postal_code": "300528502",
            "telephone_number": "770-209-9913",
            "fax_number": "678-902-8579"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3955 HARRISON RD STE 200B",
            "city": "LOGANVILLE",
            "state": "GA",
            "postal_code": "300528502",
            "telephone_number": "770-209-9913",
            "fax_number": "678-902-8579"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "REVIVE ORTHOPEDICS SPINE & SPORTS MEDICINE, INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "REVIVE ORTHOPEDICS SPINE & SPORTS MEDICINE, INC",
        "enumeration_date": "2022-12-01",
        "last_updated": "2022-12-01",
        "certification_date": "2022-12-01",
        "status": "A",
        "authorized_official_last_name": "POLLYDORE",
        "authorized_official_first_name": "SHEVIN",
        "authorized_official_middle_name": "D",
        "authorized_official_title_or_position": "PHYSICIAN/OWNER",
        "authorized_official_telephone_number": "770-209-9913",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Revive Orthopedics Spine & Sports Medicine",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Loganville, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 1, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.